Oncology Self-Study: Head and Neck Cancers and Lymphoma

Nov 02, 2017

Test your knowledge of head and neck cancers with questions from a past edition of ASCO-SEP®, ASCO’s self-evaluation program in oncology.

The fifth edition of ASCO-SEP is available for purchase in the ASCO University® bookstore. Featuring 21 updated chapters and more than 180 new self-assessment questions in the book, as well as a 120-question comprehensive mock exam online, this resource is perfect for board preparation, and can be used to earn Maintenance of Certification and continuing medical education credit. Visit university.asco.org for information about the latest edition of ASCO-SEP and other self-assessment resources.

Correct answers, rationales, and suggested reading are listed at the bottom of the page.

1. A 62-year-old man is referred to you for consultation following surgical resection of a 2.6 cm poorly-differentiated squamous cell carcinoma of the left oral tongue. Modified radical neck dissection was also performed, yielding 6 nodes, 2 of which were involved by cancer. All surgical margins were negative, but there was a spread of tumor beyond the capsule of one of the lymph nodes. Staging studies reveal no evidence of disease. His general health is good, and his performance status is ECOG 1 as he recovers from surgery.

Which of the following is the most appropriate recommendation?

Radiation to the site of the primary tumor and the neck

Radiation to the site of the primary tumor and the neck, with concurrent cisplatin chemotherapy

Cisplatin-based combination chemotherapy for 6 cycles

Observation

2. You are referred a 19-year-old woman from a university student health clinic who initially presented with 2 cm left cervical adenopathy that was thought to reflect resolving pharyngitis. When the adenopathy did not resolve with oral antibiotics, she was referred to a head and neck surgeon who discovered another 2 cm, mobile lymph node in the left supraclavicular fossa. This node was excised, showing effacement with an inflammatory infiltrate interspersed with multi-nucleate large cells that stained for CD30 and CD15, but not CD45. PA and lateral chest films showed slight prominence of the mediastinal contours, and a PET-CT showed 3-4 cm FDG-avid lymph nodes in the left hilar, mediastinal, left supraclavicular and left anterior cervical chains. A bone marrow biopsy showed normal trilineage hematopoiesis. Other than the palpable adenopathy, she is asymptomatic. Erythrocyte sedimentation rate is 45 mm/hour. Her parents accompany her to the initial clinic visit and ask you to do whatever you can to minimize treatment toxicity.

Which of the following is an acceptable treatment that minimizes risk of the leading cause of death in long-term survivors of Hodgkin Lymphoma in this patient?

Two cycles of ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) followed by 40 Gy involved-field radiotherapy

Two cycles of ABVD

Six cycles of ABVD

35 Gy subtotal nodal radiotherapy alone

Rationales

1: B

Phase III studies have demonstrated that patients with high-risk pathology benefit from the addition of cisplatin to postoperative radiation; in particular, extracapsular extension of nodal tumor was strongly associated with benefit in a pooled analysis of these trials. Adjuvant chemotherapy alone has no proven benefit.

The patient has favorable-risk stage IIA classical Hodgkin Lymphoma. The leading causes of mortality in long-term survivors of Hodgkin Lymphoma are second malignancies. Adolescent girls and young women (under age 30) are at particular risk for breast cancer, with actuarial risk as high as 34% for girls treated with mantle radiation under the age of 20. There has been increasing interest in mitigating this risk by minimizing radiation doses to 20-30 Gy and treating with involved-field radiation, which treats less normal tissue than mantle- or subtotal-nodal radiation. A randomized study comparing 4-6 cycles of ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) alone with subtotal nodal radiation-containing therapy showed superior 12-year overall survival in patients treated with ABVD alone (94% versus 87%, p=.04), largely due to lower rates of second cancers in the chemotherapy-only patients. Patients treated with chemotherapy alone were more likely to relapse than patients treated with radiation (12-year freedom-from progression 87% versus 92%, p.05), and the radiation fields in this study were subtotal nodal rather than involved field. Therefore, the optimal treatment for early stage favorable patients remains to be determined. However, acceptable strategies that provide low risk of both relapse and second breast and lung cancers are short courses (2-4 cycles) of ABVD followed by involved 20-30 Gy field radiotherapy or 4-6 cycles of ABVD alone.